EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway

So my friend, Darren Braude and one of his co-attendings had a horrible airway case, which they presented on EM:RAP. I wanted to comment on the case, because there is so much great teaching fodder. If you have access to EM:RAP, go listen to this portion on the July episode first. I say it in the show, but let me be very clear here as well–the folks involved did an incredible job. These comments are solely Monday-morning quarterbacking.

I introduce two concepts in this wee:Prepassing the bougie in the mouth and CricCon

Prepassing the bougie

I am fed up with having to look away from the cords on difficult airways, so I’ve taken to putting the bougie in the mouth at the level of the right molars before lifting to expose the glottis. A partner can do the same for you. Listen to the audio to get the full idea.

CricCon Readiness Level

Similar to the DefCon, the prior measure of US military alertness level, CricCon is what level of readiness you have to perform a cricothyrotomy. Hopefully this image explains it all:

Click here for Full Size

All airways should be level 5. Predicted difficult airways should always be at least a 4. In a “forced-to-act” situation you should be a 3. If the first attempt fails, I would move to a 2.

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Scott Weingart. EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway. EMCrit Blog. Published on July 4, 2012. Accessed on December 10th 2016. Available at [http://emcrit.org/wee/bougie-prepass-and-criccon/ ].

Discussion

I agree Scott. If you dont subscribe to EMRAP audio, do so NOW! The airway corner monthly instalment with Darren Braude is always GOLD!
This months episode is a real case discussion of a CICV situation, mainly due to extreme hypoxia. An initial intubation attempt with VL actually got a look at the cords but the tube could not be passed due to rapid desaturation.
I have commented on EMRAP already but one strategy for these forced to act RSI situations..I know Scott you do not like the term as it means a degree of loss of control..but in these cases the double setup strategy is a reasonable choice.
I am aware of one case of complete tracheal transection wherre this strategy was the only thing to save the patient.
Double setup is two operators , two airway approaches, laying siege to the trachea. Full RSI with best orotracheal intubation attempt with full cric setup, prepped and sited, pre RSI or CricCOn level3.
If oral intubator with full RSI has no joy on first pass, the cric is started immediately with BVM or LMA support from above.

Even better is to presite a 18 G or larger needle cannula via the cricothyroid membrane under LA , pre RSI. This allows oxygenation to occur during laryngoscopy from above if need be and is a site marker for surgical cric if that is needed too..if you want to do the seldinger wire thing with a Melker kit you can as well, albeit this case that mght have taken too long.

CricCon is predicated on the double set-up, so I absolutely agree. Can’t rehash the whole needle cric debate except to say that CricCon 3 would work just fine as the time to place and confirm the 18g angio, and CricCon 2 would have you passing the wire and making the scalpel cut.

Thank you for highlighting this interesting and educational case Scott.

I agree with Minh on the placing a 18g cannula with Melker kit ready pre RSI. I have utilised this technique successfully in a case of angioedema previously.

My one concern pertains to the utilisation of extra help. I just want to highlight the difference between competence and expertise in certain rarely performed task (surgical cric being a good example). All emergency and critical care physicians should be competent and willing to undertake such challenging awake intubations with extreme physiology and proceed to surgical cric if necessary. In certain resource poor and time critical environments (or in unanticipated difficult airways), this is often what is required. However, it is important to have insight into the fact just because we are competent to perform a surgical cric or awake intubation this doesn’t mean we are the best operator in such challenging scenarios. I would personally have preferred to have an experienced anaesthetist and ENT surgeon present. In such a case where the surgical cric is likely to be difficult given the BMI, I feel it is in the patient’s best interest to have an experienced ENT surgeon brandishing the scalpel and not myself. However, all these skilled hands are of no use without appropriate direction and it is important to have someone in control, providing leadership while maintaining good situational awareness.

If such help is not available I whole heartedly buy into the concept of scalpel, finger, bougie and tube. While for the majority of slim patients with good CTM anatomy I would advocate a single transverse incision, I would modify this in obese patients or those with difficult CTM anatomy. Here, I would suggest vertical incisions until anatomy is clearly identified then proceed with the horizontal incision through the CTM. I’m interested to hear other people’s thoughts on this.

Thanks again for the post and while I don’t have a nice British equivalent of ‘Monday morning quarter backing’ please take my above comments in the same vein!

Peter, your comments are well taken. I am always v. reluctant to latch on to specialties, especially in the States where things are a bit more difficult to parse. Based on NAP4, our EM folks are doing far more of the emergent airways than their EM counterparts in Great Britain. I would take your sentiment to its heart, which is to bring the most experienced folks immediately available to bear. I would gladly step aside for an experienced ENT attending/consultant for the cric, but at the same time I am sure I have performed more emergent crics than any of our ENT registrars/residents. It is the latter who would show up, not the former at our shop. A fresh EM attending may never have performed a cric on a real patient, in that case an ENT registrar may be a better choice even if they have not either b/c at least they can transfer their elective trach experience to the situation.

As to the needle vs. open cric debate, Minh and I have debated it elsewhere on the site. It comes down to one simple paradigm: do what you have trained for and can commit to. They both work. They both have advantages and disadvantages. For the folks that feel more comfortable with seldinger, that is what they should use.

a couple of weeks ago, a Spanish EM doc tweeted about a case he managed of a critically hypoxic OD patient who they were unable to preoxygenate using usual means for RSI. He remembered the needle cric oxygenation technique we had debated on EmCrit and inserted a 16G cannula via .CTM and oxygenated the patient up to 100 % by just holding the oxygen tubing to the cannula hub, intermittently at a ratio of 1:8 ..then did a successful RSI ETI.
It works and Peter I am sure can attest to this as well as I can.
Scott though is right. Do what you are prepared to complete. Its not black or white and just because you start off with one technique does not mean you cannot convert to the other. You might rapidy dissect a big fat neck in search of the trachea and due to critical hypoxia as in Braude’s case, might only have time to insert a needle cannula into the trachea once you find it, to reoxygenate before completing the open cric.
In the EMRAP episode, one of the attendings said before the case she used to regard surgical cric as a procedure of failure i.e you only do it when you have failed to tube. She now states she regards it as sometimes the procedure of primary choice in certain cases after the CICV case they encountered,
So true,

I agree completely on the ‘never equate job title to relevant experience’.

The case of angioedema I mentioned the surgeon I question I called was very confused as to what help he could offer given he had never done a surgical airway!

Moral of the story the most experienced person for the job should be present in challenging scenarios.

As for the needle vs surgical cric argument I sit on the fence. I do a lot of awake needle crics for flexible AFOI to anaesthetise the larynx. IF time allows pre-induction and you are skilled in the technique then a needle cric and melker theory is reasonable. All other circumstances including unanticipated difficult airways, CICV and CICO the surgical cric is

In CICV and CICO scenarios the surgical cric is probably the technique of choice and my preference. The NAP4 highlights the success rates of the surgical airway and superiority over the needle cric in stressful environments. But there is no right answer for all clinicians, you can only put forward the evidence and hope individuals extrapolate it to their practice in a way they feel comfortable with.

Lovely debate with no right answer! I must confess my use of needle crics its restricted to a very select patient group and a surgical cric would be my technique of choice for the majority of difficult and stressful cases.

On the topic of operators for surgical airways in the States, I read this interesting paper recently on a decade of practice in Boston trauma centres. Does this break down reflect practice in your centre Scott?

very few crics occur at our shop outside of trauma. For trauma we splite procedures by day between surgery and EM. Crics probably split about 60% surg and 40% EM. We have quite a few EM attendings that will step up and cut if necessary, but would much prefer to have the surgery trauma chief perform the procedure if he or she is already present.

While listening to this podcast, I couldn’t help but to think back to an article I had read the previous evening. The article was about a group that is working on a way to infuse oxygen in a liquid solution directly into ones vein. If this pans out it could certainly make situations like the one Darren was faced with much easier and safer to manage.

What an amazing case and a great discussion. I love the CriCon levels- it makes you aware of the fact that even what seems like a “routine” or “easy” airway may need a cric. I for one will be doing a better job of predefining the cric anatomy before I start an RSI- we should be doing it on all our patients.

As far as the patient discussed on EM:RAP- a tough case with no easy answers and the treating team did their absolute best. However, I am sure that they put this out there for discussion, dissection, and debate. So while I am sitting in my quiet air conditioned living room (and not a chaotic resus room) the thing that struck me was- what about choosing a cric as the primary approach to the airway?

I know this sounds extreme and I’m not suggesting that we go around criciing people for the fun of it. However, here is a patient who is so far behind on the oxygen and physiology curve that we all know he will tank the second you take the mask off and look from above with anything- DL, VL, LMA, or otherwise. Would this be the totally wrong approach? Would you be crucified by colleagues, hospitals, trial lawyers, or your own higher power if didn’t try to look from above and chose to do a cric as the first intervention? I know crics are not a benign procedure but neither is hypoxia and bradysystolic arrest.

While Scott’s CriCon level 2/3 approach would have worked as well- are there some airways where the scalpel should be our first choice?

Steve–I think it is a suggestion that must be thrown into the mix. Darren and I both lecture about the awake cric and you can argue this may be another way this case could have gone. I don’t think a paralyzed cric would be my first choice; I’d probably give at least one try at intubation from above, then proceed to cric.

I will put one more idea out there that I did not want to mention in the show, b/c unless you have done them and have the right equipment, they can be a clusterfuck, but I think I can mention it here in the comments:

After the 1st awake pass, this case could have been done as a retrograde intubation with the pt still awake. Pass up a wire through the membrane, pass a hollow intubating guide down the wire. Reoxygenate, then intubate over the guide, all with the pt still breathing.

can’t say I agree. Awake retrograde gets you a patient intubated from above and just a needle-hole through the membrane without losing anything if you fail. Melker cric is much more invasive and then pt still needs to be intubated from above or trached.

disagree. the gear to do awake retrograde intubation is even harder to find in any department let alone in an assembled kit. you need a wire then something to pass over the wire to cannulate the trachea..from an oral route. an airway exchange catheter or bougie with a lumen might work over the wire. Not all ED bougies I have seen have a lumen. but all that is a lot of screwing around in a time critical situation when the patient needs oxygen. If needle in trachea, then give oxygen via it and let the oral intubator have another look from above. In Braude’s case that might have worked since they got a look at cords with the VL on first attempt but desaturation aborted attempt…they just needed oxygenation support during the orotracheal intubation second attempt. but really if vyou have been able to access the trachea with a needle you got options. choose the one that is least likely to fail and waste time. aif a colleague of mine can read the Melker instructions prior to a RSI on a patient with Ludwigs angina and then successfully perform a Melker seldinger cric after a failed orotracheal intubation, and save the guys life..to me that seems more likely to work again for her rather than try something even less commonly performed, like a retrograde tube. even Dr Levitan says he has stopped teaching it during his cadaver courses. and he is a confessed scalpel open cric provider.

Phenomenal case discussion, Scott! I will give bougie prepass a shot; I dig the concept, as I hate having to look up once I’ve locked eyes on cords.

Regarding the discussion of going straight-to-cric; my take is that rarely, it can be a reasonable answer, if you look at a patient and say to yourself, “there’s no possible way I can ever intubate that guy from above.” (Think Pierre Robin syndrome with angioedema and simultaneous posterior epistaxis.) That wasn’t this patient.

I like the concept behind CricCon: a defined stepwise progression of readiness. But I wonder, half seriously, if equating cric with nuclear war will increase folks’ fear of the procedure and make it seem scarier than it needs to, and therefore less likely to get done when it needs to get done in CICO.

ignore the detractors. CricCon is brilliant concept. genius in fact. The terminology is not what engenders the fear. Its the traditional notion that it is a procedure of failure. Its our very attitudes as airway teachers that promulgate the fear. Braude’s attending colleague in the EMRAP case articulated her own prejudice about cric which underscores the origin of the fear,
Folks, Scott receives regular emails from docs around the world , thanking him for demystifying and reducing the fear around surgical airways and indeed for helping save lives with his surgical airway training concepts and tips. So whatever concepts in surgical airway Scott promotes , know this. That patients around the world are alive as a result of docs, reading his teachings and controlling their fears when the proverbial brown stuff hits the fan.

Great advice and discussion as usual. You enrich my practice so much i get teary eyed .

I have marked the cric for a long time. I do it horizontally along the cric membrane. Never had to use it since ive done this tho (altho have done 6-7 crics before). do you think it would be better to mark from thyroid cart vertically? or wouldnt my horizontal mark be better?

I am vertical cut guy. Horizontal is fine if you can feel the anatomy. First time you get a case where you cant feel anything, like Andy. Buck’s fractured larynx case we discuss on the latest PHARM podcast, you will regret having never trained the vertical incision. If you get a tracheal transection as some mates of mine had a few years ago, the horizontal cut will get you no where .I saw photos of their vertical cut from floor of mouth to sternal notch and they did find the distal transected trachea n the mediastinum, Guy made a full recovery and complete surgical repair of the whole dissection, Prepare and train for worst case. CricCon is that concept. It cant get much worse than nuclear war

Your objections are exactly why I put retrograde only in comments and not in the main show. If you are going to even consider the technique, you need a few things:

Either a commercial kit or a bougie with a lumen and a LONG wire. Just as you imply, ET over a wire is a joke

familiarity with the equipment and technique before trying it on a pt

a spontaneously breathing patient

Retrograde has gotten a bad rap b/c people think it is a failed airway technique. It is always a flail for that.

It is an awake intubation technique. I believe in my conversations with Rich, he stopped teaching it b/c pragmatically v. few people will do it and it is better to concentrate on other more common techniques. It is the same reason we don’t teach nasotracheal anymore.

Many times during intubations, easy or not, anterior neck manipulation is required. It would be difficult for the airway operator to fully “attempt” the tube placement without this maneuver. Obviously at level 3/2, this would be difficult and may contaminate the sterile field. Ways around this could include a sterile glove on the right hand of the intubator. This would allow for either manual manipulation and/or “hand holding” with the cric person until the cords are seen. At this point, the cric person could hold cord position and the sterile field would not be lost, just in case. Comments

it’s a great point; i’ll tell you what my bosses told me when they were training me to do OR trachs–if we think this is a sterile procedure, we are crazy. The betadine makes us feel better, not the pt.

Interresting discussion! As a second-year resident in anaesthesiology/intensive care-medicine (same residency in Sweden) I have only been in this kind of dramatic situation one time. I performed an open cric with scalpell, and was struck by how difficult it was to get the tube in the airway (BMI 57…). A bougie saved the pt (and my) life after a few pretracheal placements of the tube.

Now, when I have the attention of all the airway-management-silverbacks, I would like to hear your thoughts in a matter:

You are discussing the use of a 18 G needle placed in the membrane as a plan B in case your intubation attempt fails. I know a guy who placed a needle in the membrane in a pt with severe trauma to the head/neck region, to oxygenate after several attempts from above. Since the pt was completely obstructed in the larynx, the air had no way out, and he instead caused the pt a barotrauma.

In case you want to buy yourself some time when the sat falls during difficult airway management, is it working with just a needle in the membrane and passive oxygenation? Maximum flow into the needle? Lets say that larynx is totally occluded OR you cant be sure its not, is that concerning you?

I recently had similar (although less challenging) patient with terrible ARDS who was refractory to preoxygenation. I did an awake intubation with ketamine and a glidescope. High-flow nasal cannula was used throughout the procedure so that the patient kept on breathing highly oxygenated gas and maintaining her lung recruitment. The patient did desaturate during the procedure but her saturation plateaued in the low 80s and stayed there (without plummeting to zero).

I think an awake intubation strategy plus high-flow nasal cannula oxygenation is a good approach to patients with severe hypoxemia. One key to this is to realize that the oxygen desaturation curve is completely different in awake intubation compared to RSI. In RSI, when the oxygen saturation hits the 80s, it’s dropping like a stone and you have to bag the patient immediately. Alternatively, when you’re doing awake intubation with high-flow nasal oxygen, patients keep breathing and they don’t tend to drop really fast — so as long as the saturation is hanging out in the 80s you can continue with the intubation.

Josh, you are dealing with shunt at that point. You are correct that the pt shouldn’t plummet and intubation doesn’t need to cease. You might want to consider placing a bronch port onto a facemask and doing the awake on CPAP.

big fan of this Cricon idea. Simple question re jargon – you mentioned you marked up the cric site with an “industrial sharpie”. What is this? You suggested to see your ACEP lecture but I’m not sure which lecture this is or where it is located.

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Hi, my name is Scott Weingart. I am an ED
Intensivist from New York. Along with my friends, we are attempting to provide and teach Maximally Aggressive Care, Everywhere! From the field to the ICU, EMCrit is about optimal critical care and resuscitation.